Neuro-ophthalmology is a subspecialty of ophthalmology which focuses on disorders involving the eye and the brain. Almost half of the brain is used for vision-related activities including sight and eye movement. Neuro-ophthalmologists diagnose and treat visual problems related to disorders involving the nervous system, that is, visual problems that do not come from the eyes themselves.
Neuro-ophthalmologists complete at least five years of clinical training after medical school. They have unique experience and training in evaluating patients from the neurologic, ophthalmologic and medical standpoint in order to diagnose and treat a wide variety of problems.
Some of the common problems evaluated by neuro-ophthalmologists include: optic nerve disease, unexplained loss of vision, loss of peripheral vision, transient visual loss, double vision, abnormal eye movements, thyroid-related eye disease, unequal pupils, abnormalities of the eyelids and unexplained eye pain.
Neuro-ophthalmology at Wheaton Eye Clinic includes treatment of the following conditions:
Anisocoria is a condition in which the pupils in the right eye and left eye are not the same size. A small difference in pupil size is normal however, more than a small difference may indicate there is a neurologic problem. Two types of anisocoria are:
When the nerve which normally makes the pupil larger is not working properly, the pupil on that side is abnormally small and the upper eyelid droops a bit. This is called Horner Syndrome. Although having Horner Syndrome will not damage the eye or cause loss of vision, it may be a sign of damage to the nerve. It is important to find out where the damage is and what is causing it.
Examples of serious conditions causing Horner Syndrome are strokes, aneurysm or a tumor in the lung. Sometimes Horner Syndrome is due to birth trauma. Sometimes no cause can be found and the patient remains well.
Adie pupil is another condition in which the pupil is enlarged and has difficulty focusing on close objects, such as a book. Adie pupil is commonly seen in young adult women although men can develop it too. A person can have Adie pupil in one or both eyes.
There is no treatment for Adie pupil but, with time, the ability to focus up close usually returns. The Adie pupil may remain enlarged but more often shrinks in size over several years.
AION is the most common cause of sudden decreased vision in patients older than 50 years.
Most patients with AION notice a sudden blurriness, dimness or darkness, often above or below where they are looking. Central vision also may be disturbed. Usually there is no discomfort, redness or tearing. Patients with tenderness in their temples or pain when chewing may have a different cause of decreased vision and should bring these symptoms to their doctor’s attention.
There is no proven treatment for patients with AION; however, many will recover some of their vision which will then remain stable. It is important that their blood pressure be monitored and that they stop smoking.
BEB is a condition in which uncontrolled blinking, squeezing and eyelid closure occur in both eyes without outside stimulation or other apparent cause. It occurs in middle age and affects more women than men.
As the condition progresses, spasms occur more often throughout the day. Although vision is not compromised, frequent spasms may interfere with the patient’s ability to do ordinary tasks such as driving, reading, walking and shopping.
The most effective treatment for blepharospasm is therapeutic botulinum toxin, called BOTOX. A small quantity is injected under the skin, on both sides of the face, to relax and weaken the muscles in order to prevent spasms. The effect usually wears off in 3 to 6 months and injections may be repeated.
Hemifacial spasm is a chronic condition in which patients experience involuntary spasms on one side of the face.
The affected side of the face seems to “scrunch up” while the other side remains normal. These spasms may occur during the night and interrupt sleep. Middle aged men and women are affected equally.
Spasms can be brief or sustained and sometimes are triggered by facial movement.
Botulinum toxin, called BOTOX, is an effective treatment for hemifacial spasm. A small amount of BOTOX is injected under the skin at each affected site. Within a few days the BOTOX takes effect, relaxing and weakening the facial muscle and preventing spasm. The injections are done in the doctor’s office and take only 5 or 10 minutes. The effect of the BOTOX usually lasts between 3 and 6 months after which the injections may be repeated.
Microvascular cranial nerve palsy is one of the most common causes of acute double vision in older adults.
It occurs more often in patients with diabetes and high blood pressure.
Symptoms usually result from problems with eye movement and in serious cases the affected eye may not be able to move at all in one or more directions. If the eyes aren’t moving together, the patient experiences blurred or double vision.
Microvascular cranial nerve palsies recover without medical intervention although anti-inflammatory drugs, such as ibuprofen, may help with any associated pain. Until the double vision resolves, it may be alleviated by patching either eye.
A migraine headache is a form of vascular headache. Migraine headache is caused by the enlargement of blood vessels, causing the release of chemicals from nerve fibers that coil around the large arteries of the brain. This enlargement stretches the nerves around the blood vessels, causing the release of chemicals that cause inflammation, pain, and further enlargement of the artery.
Classic migraine attacks start with visual symptoms, such as zigzag colored lights or flashes of light expanding to one side over 10–30 minutes, followed by a pounding severe headache sometimes associated with nausea, vomiting and light-sensitivity. Some patients experience the visual symptoms of classic migraine without a headache. This condition is called migrainous visual aura without headache.
There are various foods that may trigger a migraine attack. These include aged cheese, nitrates found in cured meats and other processed foods, chocolate, red wine and monosodium glutamate. Hormonal changes and stress also are frequently associated with migraine.
The easiest way to avoid a migraine is to avoid foods, medications and environmental items, such as perfume, known to precipitate an attack. Sometimes over-the-counter pain medications relieve symptoms during an attack. If migraine is frequent and severe, medications may be taken on a regular basis to decrease the frequency and severity of attacks.
Optic neuritis is the most common cause of sudden visual loss in young patients between the ages of 15 and 45.
Often optic neuritis is associated with discomfort in or around the eye, particularly with eye movement. It may be difficult to diagnose because the eye may look perfectly normal.
In over 99% of cases, the pain goes away in a few days and the visual loss improves over a period of weeks or months, without treatment.
Pseudotumor cerebri is a condition in which high pressure inside the head causes loss of vision and headache.
Typically there are problems with visual loss and a steady or pounding headache, frequently at the back of the neck. The pain may worsen with bending or stooping. Patients may also be aware of a rushing noise in their ears. Nausea and vomiting sometimes occur.
By dilating the pupil, the physician looks for optic nerve swelling in the back of the eye. Then, because many conditions may produce similar signs and symptoms, a normal MRI scan and/or spinal tap may be used to diagnose the pseudotumor.
Many patients with pseudotumors do not require treatment. However, if headaches and vision loss are significant, treatment may include weight-loss, medication or surgical intervention.
In this autoimmune condition, a body’s immune system produces factors that stimulate enlargement of the muscles that move the eyes.
This condition can result in bulging of the eyes, retraction of the lids, double vision, decreased vision and eye irritation.
Often this disease is associated with abnormalities in thyroid gland function although these symptoms may be present even if the thyroid has no apparent problems.
Like other autoimmune diseases, thyroid eye disease often comes and goes on its own. Sometimes there is only one episode although the effects may persist for years. In mild cases, treatment using artificial tears and lubricating ointment, improves the symptoms of eye irritation and foreign body sensation. If the eyelids are not closing completely, they may be taped closed at night; double vision may be corrected with prisms.
In preparing for a neuro-ophthalmology Evaluation, please follow these four steps:
Request that your treating physicians send all relevant information to the Wheaton Eye Clinic prior to your appointment including office notes, results of laboratory tests and reports of CT and MRI scans.
If you had a CT or MRI scan performed, arrange to pick up the actual images on a CD and bring them with you or have the facility mail them to the Wheaton Eye Clinic in advance of your appointment.
Expect your appointment to last three to four hours, as the neuro-ophthalmology evaluation involves an extensive and thorough history as well as a careful examination along with ancillary testing. Your pupils will be dilated. The dilating drops last about four hours and will make things look bright and blurry up close.
Bring along a complete list of your medications including the name and dosage of both prescription and over-the-counter medications that you are taking.
Wheaton Eye Clinic’s unparalleled commitment to excellence is evident in our continued growth. Today we provide world-class medical and surgical care to patients in six suburban locations—Wheaton, Naperville, Hinsdale, Plainfield, St. Charles, and Bartlett.
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